Revascularization in Asymptomatic Carotid Artery Stenosis With Hemodynamic Impairment and Cognitive Outcomes: The CREST-H Substudy of the CREST-2 Randomized Clinical Trial.
Randolph S Marshall, Ronald M Lazar, James F Meschia et al.
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In 30 seconds
This multicenter substudy of a phase 3 randomized clinical trial examined whether baseline cerebral hemodynamic impairment modified cognitive outcomes after carotid revascularization in adults with high-grade asymptomatic internal carotid stenosis. Among 291 participants with complete imaging and cognitive data, the primary analysis focused on 51 with reduced baseline cognition. Over 1 year, revascularization plus intensive medical management did not produce a different cognitive outcome from intensive medical management alone (adjusted difference in cognitive z score, -0.15 SD [95% CI, -0.54 to 0.24]); the treatment-by-hemodynamic-status interaction was not significant (P = .40).
Key findings
- Among participants with reduced baseline cognition, the adjusted difference in cognitive z score over 1 year was -0.15 SD [95% CI, -0.54 to 0.24].
- Baseline hemodynamic impairment did not significantly modify the treatment effect on cognition (β estimate = 0.018 [95% CI, -0.025 to 0.061]; P = .40).
- Complete data were available for 291 participants; 51 had reduced cognition at baseline.
Why it matters
Cognitive impairment has been associated with cerebral hemodynamic impairment in asymptomatic carotid stenosis, raising the possibility that restoring flow could improve cognition. In this trial substudy, cognitive outcomes over 1 year did not differ by revascularization according to baseline hemodynamic status. The findings therefore do not support assuming that revascularization improves cognitive dysfunction through restoration of cerebral blood flow in this population.
What to keep in mind
The primary analysis included only 51 participants with reduced baseline cognition, and 1-year cognitive follow-up may not capture longer-term effects.